Inside Health

Missed Signals in New York Jails Open Way to Season of Suicides

Published: February 28, 2005

The warnings were right there in her medical file: a childhood of sexual abuse, a diagnosis of manic depression, a suicide attempt at age 13 -- all noted when Carina Montes arrived at Rikers Island in September 2002.

But none of them, state investigators said, were ever seen by the mental health specialist caring for her. He could never track down the file, which by December included another troubling fact: Ms. Montes had been placed on suicide watch by a jail social worker. Not that the suicide watch was terribly reliable; it depended in part on inmates paid 39 cents an hour to check on their suicidal peers.

In her five months at Rikers, investigators later discovered, Ms. Montes never saw a psychiatrist.

It did not, however, take a psychiatrist to pick up on the alarms she sounded near the end, when another inmate saw her tearing bedsheets and threatening to kill herself. But the guard who was called had no idea she was on suicide watch, did not notice the sheets and never reported the incident. Six hours later Ms. Montes was dead, hanging from a sheet tied to a ventilation grate.

She was 29. Her offense: shoplifting 30 lipsticks.

The death of Carina Montes was one in a spate of suicides in New York City jails in 2003 -- six in just six months, more than in any similar stretch since 1985. None of these people had been convicted of the charges that put them in jail. But in Ms. Montes's death and four of the five others, government investigators reached a stinging judgment about one or both of the authorities responsible for their safety: Prison Health Services, the nation's largest for-profit provider of inmate medical care, and the city correction system.

In their reports, investigators faulted a system in which patients' charts were missing, alerts about despondent inmates were lost or unheeded, and neither medical personnel nor correction officers were properly trained in preventing suicide, the leading cause of deaths in American jails.

Prison Health came to Rikers in 2001 after signing a three-year, $254 million contract and promising to deliver the health care that, compared with jails around the country, had helped make New York something of a model. And it spoke confidently about tackling the jails' biggest problem: how to handle their vast and volatile population of the mentally ill.

The rash of suicides, and nine more during Prison Health's tenure, is one measure of the company's uneven and at times troubling record in meeting that challenge. But there are others.

Ten psychiatrists with foreign medical degrees were allowed to practice without state certification for more than a year after they were supposed to have been fired for failing to pass the necessary test. When it finally dismissed them on the city's orders in 2003, Prison Health was left with about one-third of its full-time psychiatrist positions empty, according to city health department figures.

The company has employed five doctors with criminal convictions, including one who had been jailed for selling human blood for phony tests to be billed to Medicaid. In all, at least 14 doctors who have worked for Prison Health have state or federal disciplinary records, among them a psychiatrist forbidden to practice in New Jersey after state officials blamed him for a patient's fatal drug overdose.

The city's Board of Correction, an oversight agency that sets minimum standards for jails, has complained that the company shuffles doctors from jail to jail -- regardless of where they are needed -- to avoid city fines and create the illusion that each building is properly staffed.

Many of the 30 current or former Prison Health employees interviewed for this article described an effort that, whatever its good intentions, frequently fails to adequately treat the mental illnesses that inmates take into jail and that follow them back out.

Dr. Douglas Cooper, a psychiatrist who helped supervise mental health treatment at the nine Rikers jails until, he says, he quit in frustration in 2003, summed up the care as triage, buffeted by a sense of nonstop crisis. ''The staff does the best they can,'' he said, ''and what's left they sweep under the rug.''

Prison Health Services, a Nashville-area corporation that bills itself as the gold standard of jail health care, says it has done a solid job at Rikers and a 10th jail, in Lower Manhattan, caring for more than 100,000 inmates a year as part of its largest contract among scores across the nation.

The company says it has worked hard to find qualified mental health specialists, held increases in medical expenses below the national average, and saved the city hundreds of thousands of dollars.

There is little dispute that New York City has long insisted on more generous jail care than most other places; the suicide rate, even under Prison Health, is about half the national average for jails.

Then again, the rate was lower before Prison Health arrived. And in the four years since, the rate of suicides at Rikers has been higher than in the Los Angeles jail system, the largest and one of the most violent in the nation.